Appointment Registration Form

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Appointment Registration Form

We will do our best to contact you the same or next business day following your request, but current response time may be delayed. If your pet is currently experiencing symptoms, please call our offices to speak with a staff member for the fastest service.
Select a Location
Select your closest state:*
Maryland*
Please select your preferred location. If you already have an appointment, please select the location where your appointment is scheduled.
- Annapolis, MD
- Columbia, MD
- Frederick, MD
- Gaithersburg, MD
- Hunt Valley, MD
- Rockville, MD
Colorado*
Please select your preferred location. If you already have an appointment, please select the location where your appointment is scheduled.
- Wheat Ridge, CO
- Loveland, CO
- Boulder, CO
- Castle Rock, CO
Virginia*
Please select your preferred location. If you already have an appointment, please select the location where your appointment is scheduled.
- Fairfax, VA
- Leesburg, VA
- Richmond, VA
- Springfield, VA
- Vienna, VA
Massachusetts*
Please select your preferred location:
- Waltham, MA
Kentucky*
Please select your preferred location:
- Louisville, KY
California*
Please select your preferred location:
- San Juan Capistrano, CA
Florida*
Please select your preferred location:
- West Palm Beach, FL
North Carolina*
Please select your preferred location:
- Cary, North Carolina
Texas*
Please select your preferred location. If you already have an appointment, please select the location where your appointment is scheduled.
- NW Austin, TX
- Shoal Creek - Austin, TX
- Flower Mound (TeleCardiology) - Flower Mound, Texas
Oregon*
Please select your preferred location. If you already have an appointment, please select the location where your appointment is scheduled.
- Portland-Hollywood
- Portland-Milwaukie
Appointments for TeleCardiology are provided by referral only and are available for asymptomatic (stable) pets as diagnostics are performed without direct onsite veterinary supervision and results are communicated to your pet's veterinary care provider. If you have not had a referral submitted on your pet's behalf and you are interested in scheduling with TeleCardiology by CVCA, please discuss with your pet's veterinary care provider if TeleCardiology is the best option for your pet. Has your pet's veterinary care provider submitted a referral for your pet?*
- Yes
- No
Has this pet been to CVCA before?*
- Yes
- No
Please put 'no' if you have NOT brought this pet to CVCA before, even if you have previously been a client with us.
Would you like to set up an appointment?*
- Yes
- No, I already have an appointment
When is your appointment?*
Are you requesting a new appointment or a recheck?*
- New
- Recheck
Hidden
Do you have a preferred appointment date / time?
Our hours are Monday-Friday 9 a.m. - 5 p.m. EST
Preferred Days (Optional)
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Preferred Days (Optional)
- Monday
- Tuesday
- Wednesday
- Thursday
Preferred Time (optional)
- AM
- PM
Most offices are open Monday-Friday from 9 AM - 5 PM.
Maryland - Do you have a preferred doctor?
Virginia - Do you have a preferred doctor?
Texas - Do you have a preferred doctor?
Oregon - Do you have a preferred doctor?
Primary Owner
First Name*
Last Name*
Preferred Pronouns:
- She/Her
- He/Him
- They/Them
- Other
Preferred pronouns:*
Contact Information
As provided in CVCA’s email confirming your appointment, have there been any changes to your home address or contact information?*
- No changes
- Yes
Phone (Please Include Area Code)*
Hidden
Phone Type?
- Mobile
- Landline
Email*
Address*
Street Address City State Zip
Does anyone else have permission to make decisions on behalf of your pet?*
- Yes
- No
Please list their name and contact information.*
Please list changes to your home address or contact information.*
Do you work in the veterinary profession?
- I am a veterinarian.
- I am a veterinary professional.
If you answered yes to the above, please list your position and place of employment.
Are you a member of the military on active duty?
- I am a member of the military on active duty.
Do you have pet insurance?*
- Yes
- No
Who is the provider and what is the policy number?*
Pet Information and Medical History
Pet's Name*
Species of Pet*
- Canine
- Feline
Date of Birth/Approximate Age*
Sex of Pet*
- Female--Spayed
- Female--Not Spayed
- Male--Neutered
- Male--Not Neutered
Breed of Pet*
Color of Pet*
Please check this box if the patient is owned by a 501(c)(3) non-profit rescue, shelter or government agency (Military, ATF, USDA etc)
- Yes, this patient is owned by a 501(c)(3) non-profit rescue, shelter, or government agency.
If you answered yes to the above, please list the name & phone number for the rescue, shelter, or agency.

Name & Phone Number
Name of your primary care veterinarian practice? Please include the city the practice is located in:*
Who is your primary care veterinarian?*
Approximate date of last visit to your primary care veterinarian:*
Other veterinarian or specialist and approximate date of last visit:
Preferred Pharmacy (Name, address, phone number):
Do any of your pet's relatives have heart disease?*
Has your dog/cat had any extensive travel history or adopted/lived outside of your current state of residence, in particular to the southwestern United States or overseas?*
Are any surgeries or dentistries planned?*
- Yes
- No
What is the primary reason for your pet's visit or referral?*
Please check any of the following symptoms your pet is experiencing.*
- Weakness/Lethargy
- Collapsing
- Vomiting
- Diarrhea
- None of These
Please describe the weakness/lethargy.*
When was the first episode of collapse? How many episodes has the pet had?*
What was the pet doing before, during, and after the collapse?*
How long did the collapsing event last?*
How long until the pet was normal (i.e. able to stand, walk and respond normally)?*
Please describe the vomiting.*
Please describe the diarrhea.*
Is your pet coughing?*
- Yes
- No
How frequently are they coughing?*
When did the cough start? Has it been getting worse since the cough was first noted?*
Have you noticed a change in pet's breathing rate or effort?*
- No/Normal
- Yes/Abnormal
Please describe.*
Have you noticed a change in your pet's activity level or tolerance to exercise?*
- No change/normal
- Yes/Abnormal
Please describe.*
How is your pet's appetite?*
- Excellent
- Good/Normal
- Poor/Decreased
- Currently Not Eating
Is this a recent change in appetite?*
- No
- Yes
When did the change start? Was it gradual or sudden?*
What commercial brand along with the flavor/variety food do you feed your dog/cat? If you feed a homemade or raw diet, please elaborate on what you are specifically feeding your pet? (Write below or upload a photo)
Please upload a photo of your pet's food, if commercial brand.
Drop files here or

Max. file size: 100 MB.
How is your pet's water consumption?*
- More than normal
- Normal
How is your pet's urination frequency?*
- More than normal
- Normal
What medications is your pet currently taking (including preventatives and supplements)?*
Please list medication name, dosage (in mg), and directions/usage for each medication. If none, say 'none'.
Is there anything else we should know prior to the appointment? (Pet temperament, previous issues, sedatives prior to exam today, any other concerns about his/her cardiac health for this appointment)?
Hidden
Counting the pet(s) that you would like to bring to CVCA, what species of pet do you own?
Hidden
If 'other', what other species of pet do you own?*
Cardio-Pulmonary Resuscitation (CPR): In the unlikely event that your pet should have Cardio-Pulmonary arrest while in our care, what are your wishes in regards to attempted resuscitation?*
- I authorize CPR should my pet arrest while in the care of CVCA Cardiac Care for Pets
- Please do NOT perform CPR
Please note that we will make every attempt to contact you. Please ask for us to explain these choices further if you have any additional questions or concerns.
TeleCardiology Services: I understand that the sonography scan will be performed by a registered sonographer and transmitted to a remotely located board-certified veterinary cardiologist and results will be discussed with my pet's veterinary care provider only. It will be the responsibility of the veterinary care provider who referred my animal for these consultatory diagnostic services to communicate all of the results and treatment recommendations to me as the owner/responsible agent of the pet named above, and the sonographer and CVCA team cannot communicate information regarding diagnosis or treatment. CVCA Telecardiology will NOT be able to speak directly to me as the animal owner regarding results or recommendations.*

Signature
Consent for transfer to Emergency Care: TeleCardiology is available for asymptomatic (stable) pets only as diagnostics are performed without direct onsite veterinary supervision. If our CVCA staff determines that your pet requires veterinary assessment, treatment, or care, your pet will be immediately transferred to the Flower Mound Veterinary Emergency & Specialty Center for evaluation and continued care. Your signature below provides authorization for CVCA's TeleCardiology services within these parameters.*

Signature
In the unlikely event that your pet should have Cardio-Pulmonary arrest while in our care, and is then transferred to the Flower Mound Veterinary Emergency & Specialty Center for evaluation and continued care, what are your wishes in regards to attempted resuscitation?*
- I authorize CPR should my pet arrest while in the care of CVCA Cardiac Care for Pets
- Please do NOT perform CPR
Please note that we will make every attempt to contact you. Please ask for us to explain these choices further if you have any additional questions or concerns.
Signature*
Sedation: The majority of our patients do not require sedation for any of CVCA's tests or procedures; however, in the uncommon event the doctor deems injectable sedation necessary for your pet, please choose one of the following:*
- I authorize injectable sedation.
- I prefer a discussion with CVCA prior to injectable sedation.
- I do not authorize sedation.
Signature*
May CVCA offer treats to your pet during his/her office visit?*
- Yes
- No
(Optional): Photo of Your Pet
Max. file size: 100 MB.
How did you hear about CVCA?*
Contact Methods
CVCA Marketing is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, you may consent to any of the following below. You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.
Would you like to sign up for text message reminders?*
- Yes
- No
Would you like to sign up for CVCA marketing emails?*
- Yes
- No
This includes a pet owner-focused quarterly newsletter, event announcements, and any CVCA pertinent updates. Approx. 1 email every 2 months.
Photo Release - Can we take/use photos of your pet to highlight them on our Facebook page/social media/newsletter?*
- Yes
- No
Signature, Release, and Agreement
I have reviewed and understand CVCA's Protocol and agree to the adjusted workflow. I understand that payment in full is due at the time of service and under CVCA's guidelines agree to pay CVCA no later than 5:00 pm on the day that services are rendered. I agree to assume financial responsibility for all professional fees and understand that a service fee of 1.5% will be charged on any unpaid balance. CVCA may also recover reasonable attorney’s fees and court costs incurred as a result of my failure to pay in accordance with this authorization.
Signature*
Check Box & Click Submit Below to Complete Form Submission
By clicking submit below, you consent to allow CVCA Cardiac Care for Pets to store and process the personal information submitted above to provide you the content requested.
Email
This field is for validation purposes and should be left unchanged.

Be Kind

Please be kind as our team does their best to provide the highest standard of care for you and your pets. CVCA will NOT tolerate offensive behavior toward our team members.

Appointment Registration Form

Appointment Registration Form

Select a Location

Primary Owner

Contact Information

Pet Information and Medical History

Contact Methods

Signature, Release, and Agreement

Check Box & Click Submit Below to Complete Form Submission

Be Kind

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